Sign-Up Sheet

Dental Implant Referral List

This web site is Number One in the search engines and has been so for over ten years. Approximately 6,000 people visit the dental-implants.com every week. Many of them are potential patients who are looking for information about dental implants and a recommendation for someone in their area who places and/or restores dental implants. In the past, I have provided a free minimal referral service that has benefitted hundreds of dentists. In 2006 I have decided to develop this end of the web site and make dental-implants.com the major referal source for patients on the World Wide Web.

The Following Will Apply as of March 1, 2006 :

There will be a fee of $1,000.00 per year for each dentist who wishes to list themselves on dental-implants.com
This fee will give you an exclusive listing in your area and will include a detailed description of your dental implant services
A national promotional campaign of Dental-implants.com will begin once sufficient membership has been achieved to promote the web site further and enhance referals.

If you are interested in joining this exciting new service, completely fill out the form below and you will be contacted in the near future. SRD

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Name:

Address:

Phone: Fax: Email:

URL of your Web Page:

Dental School: Year of Graduation:

Implant Training:

Specialty Training: Board Certification (Date):

Number of Years Placing Implants: Number of years restoring Implants:

Professional Highlights:

Publications:
Teaching Affiliations:
Recent Presentations:

Additional Comments: